Basic Information
Provider Information | |||||||||
NPI: | 1770738791 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CUBA MEMORIAL HOSPITAL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 140 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | CUBA | ||||||||
State: | NY | ||||||||
PostalCode: | 147271317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5859682000 | ||||||||
FaxNumber: | 5859683898 | ||||||||
Practice Location | |||||||||
Address1: | 140 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | CUBA | ||||||||
State: | NY | ||||||||
PostalCode: | 147271317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5859682000 | ||||||||
FaxNumber: | 5859683898 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2008 | ||||||||
LastUpdateDate: | 01/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KERLING | ||||||||
AuthorizedOfficialFirstName: | NORMA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5859686751 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 0226700C | NY | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 03196283 | 05 | NY |   | MEDICAID |